Spinal cord injury (SCI) refers to an injury to the spinal cord. It can cause myelopathy or damage to nerve roots or myelinated fiber tracts that carry signals to and from the brain.[1][2] Depending on its classification and severity, this type of traumatic injury could also damage the grey matter in the central part of the cord, causing segmental losses of interneurons and motorneurons.
Contents
[hide]
* 1 Classification
* 2 Signs and symptoms
o 2.1 By location
+ 2.1.1 Cervical injuries
+ 2.1.2 Thoracic injuries
+ 2.1.3 Lumbar and sacral injuries
+ 2.1.4 Other syndromes
* 3 Causes
* 4 Treatment
o 4.1 Occupational therapy
+ 4.1.1 Phase 1: Acute Recovery
+ 4.1.2 Phase 2: Acute Rehabilitation
+ 4.1.3 Phase 3: Community reintegration
* 5 Epidemiology
* 6 Research directions
* 7 See also
* 8 References
o 8.1 External links
[edit] Classification
The American Spinal Injury Association (ASIA) defined an international classification based on neurological responses, touch and pinprick sensations tested in each dermatome, and strength of ten key muscles on each side of the body, e.g. shoulder shrug (C4), elbow flexion (C5), wrist extension (C6), elbow extension (C7), hip flexion (L2). Traumatic spinal cord injury is classified into five categories by the American Spinal Injury Association and the International Spinal Cord Injury Classification System:
* A indicates a "complete" spinal cord injury where no motor or sensory function is preserved in the sacral segments S4-S5.
* B indicates an "incomplete" spinal cord injury where sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-S5. This is typically a transient phase and if the person recovers any motor function below the neurological level, that person essentially becomes a motor incomplete, i.e. ASIA C or D.
* C indicates an "incomplete" spinal cord injury where motor function is preserved below the neurological level and more than half of key muscles below the neurological level have a muscle grade of less than 3, which indicates active movement with full range of motion against gravity.
* D indicates an "incomplete" spinal cord injury where motor function is preserved below the neurological level and at least half of the key muscles below the neurological level have a muscle grade of 3 or more.
* E indicates "normal" where motor and sensory scores are normal. Note that it is possible to have spinal cord injury and neurological deficits with completely normal motor and sensory scores.
In addition, there are several clinical syndromes associated with incomplete spinal cord injuries.
* The Central cord syndrome is associated with greater loss of upper limb function compared to lower limbs.
* The Brown-Séquard syndrome results from injury to one side with the spinal cord, causing weakness and loss of proprioception on the side of the injury and loss of pain and thermal sensation of the other side.
* The Anterior cord syndrome results from injury to the anterior part of the spinal cord, causing weakness and loss of pain and thermal sensations below the injury site but preservation of proprioception that is usually carried in the posterior part of the spinal cord.
* Tabes Dorsalis results from injury to the posterior part of the spinal cord, usually from infection diseases such as syphilis, causing loss of touch and proprioceptive sensation.
* Conus medullaris syndrome results from injury to the tip of the spinal cord, located at L1 vertebra.
* Cauda equina syndrome is, strictly speaking, not really spinal cord injury but injury to the spinal roots below the L1 vertebra.
[edit] Signs and symptoms
Divisions of Spinal Segments Gray 111 - Vertebral column-coloured.png
Segmental Spinal Cord Level and Function
Level Function
C1-C6 Neck flexors
C1-T1 Neck extensors
C3, C4, C5 Supply diaphragm (mostly C4)
C5, C6 Shoulder movement, raise arm (deltoid); flexion of elbow (biceps); C6 externally rotates the arm (supinates)
C6, C7 Extends elbow and wrist (triceps and wrist extensors); pronates wrist
C7, T1 Flexes wrist
C7, T1 Supply small muscles of the hand
T1 -T6 Intercostals and trunk above the waist
T7-L1 Abdominal muscles
L1, L2, L3, L4 Thigh flexion
L2, L3, L4 Thigh adduction
L4, L5, S1 Thigh abduction
L5, S1, S2 Extension of leg at the hip (gluteus maximus)
L2, L3, L4 Extension of leg at the knee (quadriceps femoris)
L4, L5, S1, S2 Flexion of leg at the knee (hamstrings)
L4, L5, S1 Dorsiflexion of foot (tibialis anterior)
L4, L5, S1 Extension of toes
L5, S1, S2 Plantar flexion of foot
L5, S1, S2 Flexion of toes
The effects of a spinal cord injury may vary depending on the type, level, and severity of injury, but can be classified into two general categories:
* In a complete injury, function below the "neurological" level is lost. Absence of motor and sensory function below a specific spinal level is considered a "complete injury". Recent evidence suggests that less than 5% of people with "complete" spinal cord injuries recover locomotion.[citation needed]
* In an incomplete injury, some sensation and/or movement below the level of the injury is retained. The lowest spinal segment in humans is located at vertebral levels S4-5, corresponding to the anal sphincter and peri-anal sensation. The ability to contract the anal sphincter voluntarily or to feel peri-anal pinprick or touch, the injury is considered to be "incomplete". Recent evidence suggests that over 95% of people with "incomplete" spinal cord injuries recover some locomotor function.[citation needed]
In addition to loss of sensation and motor function below the level of injury, individuals with spinal cord injuries will also often experience other complications:
* Bowel and bladder function is regulated by the sacral region of the spine. In that regard, it is very common to experience dysfunction of the bowel and bladder, including infections of the bladder and anal incontinence, after traumatic injury.
* Sexual function is also associated with the sacral spinal segments, and is often affected after injury. During a psychogenic sexual experience, signals from the brain are sent to spinal levels T10-L2 and in case of men, are then relayed to the penis where they trigger an erection. A reflex erection, on the other hand, occurs as a result of direct physical contact to the penis or other erotic areas such as the ears, nipples or neck. A reflex erection is involuntary and can occur without sexually stimulating thoughts. The nerves that control a man’s ability to have a reflex erection are located in the sacral nerves (S2-S4) of the spinal cord and could be affected after a spinal cord injury.[3]
* Injuries at the C-1/C-2 levels will often result in loss of breathing, necessitating mechanical ventilators or phrenic nerve pacing.
* Inability or reduced ability to regulate heart rate, blood pressure, sweating and hence body temperature.
* Spasticity (increased reflexes and stiffness of the limbs).
* Neuropathic pain.
* Autonomic dysreflexia or abnormal increases in blood pressure, sweating, and other autonomic responses to pain or sensory disturbances.
* Atrophy of muscle.
* Superior Mesenteric Artery Syndrome.
* Osteoporosis (loss of calcium) and bone degeneration.
* Gallbladder and renal stones.
[edit] By location
Determining the exact level of injury is critical in making accurate predictions about the specific parts of the body that may be affected by paralysis and loss of function.
The symptoms observed after a spinal cord injury differ by location (refer to the spinal cord map on the right to determine location). Notably, while the prognosis of complete injuries are generally predictable, the symptoms of incomplete injuries span a variable range. Accordingly, it is difficult to make an accurate prognosis for these types of injuries.
[edit] Cervical injuries
Cervical (neck) injuries usually result in full or partial tetraplegia (Quadriplegia). However, depending on the specific location and severity of trauma, limited function may be retained.
* C3 vertebrae and above : Typically results in loss of diaphragm function, necessitating the use of a ventilator for breathing.
* C4 : Results in significant loss of function at the biceps and shoulders.
* C5 : Results in potential loss of function at the shoulders and biceps, and complete loss of function at the wrists and hands.
* C6 : Results in limited wrist control, and complete loss of hand function.
* C7 and T1 : Results in lack of dexterity in the hands and fingers, but allows for limited use of arms. C7 is generally the threshold level for retaining functional independence.
[edit] Thoracic injuries
Injuries at or below the thoracic spinal levels result in paraplegia. Function of the hands, arms, neck, and breathing is usually not affected.
* T1 to T8 : Results in the inability to control the abdominal muscles. Accordingly, trunk stability is affected. The lower the level of injury, the less severe the effects.
* T9 to T12 : Results in partial loss of trunk and abdominal muscle control.
[edit] Lumbar and sacral injuries
The effects of injuries to the lumbar or sacral regions of the spinal cord are decreased control of the legs and hips, urinary system, and anus.
[edit] Other syndromes
Central cord syndrome is a form of incomplete spinal cord injury characterized by impairment in the arms and hands and, to a lesser extent, in the legs. This is also referred to as inverse paraplegia, because the hands and arms are paralyzed while the legs and lower extremities work correctly.
Most often the damage is to the cervical or upper thoracic regions of the spinal cord, and characterized by weakness in the arms with relative sparing of the legs with variable sensory loss.
This condition is associated with ischemia, hemorrhage, or necrosis involving the central portions of the spinal cord (the large nerve fibers that carry information directly from the cerebral cortex). Corticospinal fibers destined for the legs are spared due to their more external location in the spinal cord.
This clinical pattern may emerge during recovery from spinal shock due to prolonged swelling around or near the vertebrae, causing pressures on the cord. The symptoms may be transient or permanent.
Anterior cord syndrome is also an incomplete spinal cord injury. Below the injury, motor function, pain sensation, and temperature sensation is lost; touch, proprioception (sense of position in space), and vibration sense remain intact. Posterior cord syndrome (not pictured) can also occur, but is very rare.
Brown-Séquard syndrome usually occurs when the spinal cord is hemisectioned or injured on the lateral side. On the ipsilateral side of the injury (same side), there is a loss of motor function, proprioception, vibration, and light touch. Contralaterally (opposite side of injury), there is a loss of pain, temperature, and deep touch sensations
[edit] Causes
Spinal cord injury can occur from many causes, including:
* Trauma such as automobile crashes, falls, gunshots, diving accidents, war injuries, etc.
* Tumor such as meningiomas, ependymomas, astrocytomas, and metastatic cancer.
* Ischemia resulting from occlusion of spinal blood vessels, including dissecting aortic aneurysms, emboli, arteriosclerosis.
* Developmental disorders, such as spina bifida, meningomyolcoele, and others
* Neurodegenerative diseases, such as Friedreich's ataxia, spinocerebellar ataxia, etc.
* Demyelinative diseases, such as Multiple Sclerosis.
* Transverse myelitis, resulting from stroke, inflammation, or other causes.
* Vascular malformations, such as arteriovenous malformation (AVM), dural arteriovenous fistula (AVF), spinal hemangioma, cavernous angioma and aneurysm.
[edit] Treatment
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Treatment options for acute, traumatic non-penetrating spinal cord injuries include the administration of a high dose of an anti-inflammatory agent, methylprednisolone, within 8 hours of injury. This recommendation is primarily based on the National Acute Spinal Cord Injury Studies (NASCIS) I and II. However, in a third study, methylprednisolone failed to demonstrate an effect in comparison to placebo. Additionally, due to increased risk of infections, the use of this anti-inflammatory drug after spinal cord injuries is no longer recommended.[4][5] Presently, administration of cold saline acutely after injury is gaining popularity, but there is a paucity of empirical evidence for the beneficial effects of therapeutic hypothermia.
One as yet uncommon approach to improve chances of recovery is to increase blood pressure, using e.g. neosynephrine, thereby counteracting a possible underprovision of nerve cells.[6][7]
[edit] Occupational therapy
Occupational therapy plays an important role in the rehabilitation and management of SCI at all levels. An important therapeutic goal is to assist the client to restore function, enabling clients to participate in the activities and tasks that are important to them. The ability to participate in meaningful, everyday activities is essential to an individual’s health and well-being.
Occupational therapists (OTs) focus on three life areas, which include self-care, productivity, and leisure.[8] Self-care tasks include basic needs such as bathing, hygiene, feeding, and dressing. Productivity includes activities such as paid work, volunteering, care-giving, or parenting. Leisure includes fun and enjoyable activities activities typically done during spare time. Performing daily activities can be difficult for an individual with a spinal cord injury. However, through the rehabilitation process individuals with SCI can live independently in the community with or without full-time attendant care, depending on the level of their injury.[9]
Occupational therapists work collaboratively with their clients to identify challenges in the performance of daily tasks and activities related to self-care, productivity and leisure.[10] Informal and formal assessments help OTs gain information that helps them to understand their clients' challenges.
Pallastrini et al. [11] emphasize the importance of early occupational therapy, started immediately after the client is stable. During these early stages, OTs evaluate what the client is able to do and what the client is having difficulty with. Occupational therapists then work one-on-one with the client on skills required for daily living. The client is shown new ways of doing things and may be given assistive devices or equipment. Occupational therapists also help their clients develop coping skills, and implement exercises and routines that strengthen muscles.[11]
[edit] Phase 1: Acute Recovery
During acute recovery, the focus is on support and prevention. The OT helps the client gain a sense of control over a situation in which the client likely feels little independence.[9] The OT may make splints to prevent deformities in the hands. Additionally, daily arm and hand exercises are performed to maintain normal function. Fitting and selecting the most appropriate temporary wheelchair to enable mobility is important in this stage. Finally, teaching the client and care providers appropriate positioning in bed and in the wheelchair is critical for the prevention of pressure sores.[9] Education regarding pressure sore prevention continues into the rehabilitation phase. See self-care skills.
[edit] Phase 2: Acute Rehabilitation
During acute rehabilitation, OT interventions focus on support, education for the client and family/caregivers, meaningful activities, choosing equipment and restoring the client’s self esteem and confidence.[9] It is particularly important to consider the client’s discharge environment (i.e. home, community and social setting) in order to prepare for community living. With the client, the OT creates an individual program to meet the client's needs. The following are key areas of intervention common to numerous rehabilitation settings [12] :
Assessment and treatment of the upper limbs.
Early in the rehabilitation phase, the OT and/or Physical Therapist evaluates the client’s strength and sensation in the upper extremity (UE) and lower extremity (LE). The OT makes use of therapeutic activities to both strengthen muscles and improve hand function. Custom-made splints are commonly used to help position the hands in a functional position and assist in preventing deformity.[12] Individuals who retain wrist function are taught to use tenodesis grasp (extending the wrist to bring the thumb and index finger together and flexing the wrist to separate the thumb and index finger) for picking up and releasing light objects.[9] Using meaningful activities to build strength, endurance, and coordination helps to differentiate the work of occupational therapists from physical therapists.
Self care retraining.
Obtaining competency in self-care tasks contributes significantly to an individual's sense of self confidence and independence. The focus is on feeding, grooming, bathing, dressing and bowel/bladder management.[9] Assistive devices and specialized equipment are prescribed by the OT to help the client achieve greater competency and independence in their activities of daily living.
Pressure sores are secondary complications of SCI. Educating clients about the risks that lead to pressure sores and strategies for prevention is important to health and well-being.[12]
Transfer skills.
Transfers are a key area of education and skill development.[12] Examples of different transfers include: moving from bed to wheelchair, from wheelchair to toilet or tub, and from wheelchair to driver’s seat. Strength in the upper extremities makes it possible to transfer independently from one surface to another either with the aid of a sliding transfer board or by utilizing grab bars. Frequent practice under the guidance of the OT assists clients with the necessary skill development.
Bed mobility.
Occupational therapists teach their clients bed mobility skills required for many daily tasks, such as getting dressed, moving out of bed, and correct positioning in bed for skin protection and comfort.[12]
Mobility skills.
Not being able to move around without help is the largest restriction to participating in activities of daily living. The wheelchair that a person uses can significantly affect their quality of participation. A key area for the OT is to assist clients with the selection of the most suitable mobility aid in accordance with their needs, finances, abilities, preferences and available technology.[13] A proper fitting wheelchair is critical for good posture and comfort. Creating an ideal match between the client's needs and the equipment available is challenging. The client's level of funding and the high cost of equipment adds further complexity.[13]
The level and severity of a clients SCI determines the most suitable mobility aid. For example, some clients require a power wheelchair both indoors and outdoors while others can manage on both terrains using a manual wheelchair. If a client requires assistance with uneven outdoor surfaces, the OT may prescribe both a power and manual wheelchair to allow for flexibility according to their needs. This involves fitting clients for both wheelchairs and selecting the best pressure relieving surfaces/cushions and backrests. In addition, power and manual wheelchair training assists clients in developing skills both indoors and outdoors.
Home assessment and modifications.
Where possible, the OT will make a home visit to assess the need for changes and adaptations to the home. Examples of common adaptations include: adding ramps or lifts to get into the home, widening doorways, adapting the bathroom and kitchen for wheelchair accessibility, placing electrical switches at wheelchair level, and choosing wheelchair-friendly flooring. Assessing the need for specialized equipment (i.e. hospital bed or pressure relieving mattress) also takes place during rehabilitation. The client will be encouraged to try different pieces of equipment in relation to self-care, communication, and other activities of daily living.
Domestic retraining.
During rehabilitation, opportunities are provided for clients to practice a variety of domestic skills. For example, clients can practice cooking in a wheelchair-accessible kitchen. They can trial different pieces of equipment that can enhance independence in this area. A variety of adaptive aids for the kitchen address limitations in grip strength.[11] Occupational therapists teach adaptive strategies for carrying out domestic chores (i.e. childcare, cleaning, laundry) that are adjusted to suit the client's needs and abilities. It may be necessary to hire a community home care support worker to assist with domestic chores. The amount of additional outside support depends on the level and severity of the client's SCI and can vary from 24 hours per day to just a few hours per day.[9]
Assistance with return to driving/transportation.
Clients who are able to transfer independently from their wheelchair to the driver’s seat using a sliding transfer board, are candidates for returning to driving. Complete independence with driving also requires the ability to load and unload one’s wheelchair from the vehicle.[9] Clients capable of driving are referred by the OT to the 'Return to driving program' within the Driver Assessment and Rehabilitation Unit at the hospital. The goal of the program is to provide education and retraining to help clients return to driving. Assistance with selecting an appropriate modified vehicle that will meet the client’s needs and budget are part of the program. For clients who do not wish to return to driving, alternate transportation options are also addressed (i.e. accessible parking, taxi subsidy vouchers, modified vehicle for passenger transit and public transportation).
Community living skills.
Clients may be involved in a support group, which addresses skills that prepare clients for returning home and to the community. As previously mentioned, driving and wheelchair mobility skills are important for accessing the community. Community outings are commonly organized to help transition the client into the community.[12] (See community reintegration for more details.)
Leisure and recreation skills.
Part of rehabilitation involves investigating options for returning to previous leisure/recreation interests as well as developing new pursuits. In addition, the OT can assist the client in finding ways to cope with physical and social issues that may get in the way of leisure participation.[14]
Work/study skills.
Addressing the client's career and educational goals is very important. If appropriate, a work site/school visit may be arranged to assess for accessibility. Otherwise, a referral to a community based work/school assessment service may be indicated.[14]
Sexual Health.
Exploring concerns related to sexual health and function should form an integral part of each client's treatment plan. The OT can assist their client by providing information and identifying alternate resources and adaptive devices as needed.[14]
[edit] Phase 3: Community reintegration
Following rehabilitation, the client begins the process of community reintegration. Community participation is an important aspect in maintaining quality of life.[15] During community reintegration, the focus of occupational therapy is on restoring client roles at home and in the community, and promoting social participation and life satisfaction.[15] Ongoing education of the client, family and caregivers continues throughout this stage. Referrals can be made to an outpatient clinic or community therapist to continue with treatment and progress made during rehabilitation. Outpatient programs teach clients how to use new movement and they offer training for activities of daily living as clients continue to gain strength during the first year after injury.
[edit] Epidemiology
One can have spine injury without being involved in some form of traumatic injury. Many people suffer transient loss of function ("stingers") in sports accidents or pain in "whiplash" of the neck without neurological loss and relatively few of these suffer spinal cord injury sufficient to warrant hospitalization. In the United States, the incidence of spinal cord injury has been estimated to be about 40 cases (per 1 million people) per year or 12,000 cases per year .[16] In China, the incidence of spinal cord injury is approximately 60,000 per year.[17]
The prevalence of spinal cord injury is not well known in many large countries. In some countries, such as Sweden and Iceland, registries are available. According to new data collected by the Christopher and Dana Reeve Foundation, in the US, there are currently 1.3 million individuals living with spinal cord injuries- a number five times that previously estimated in 2007. 61% of spinal cord injuries occur in males, and 39% in females. The average age for spinal cord injuries is 48 years old. There are many causes leading to spinal cord injuries. These include motor vehicle accidents (24%), work-related accidents (28%), sporting/recreation accidents (16%), and falls (9%).[citation needed]
[edit] Research directions
Scientists are investigating many promising avenues for treatment of spinal cord injury. Numerous articles in the medical literature describe research, mostly in animal models, aimed at reducing the paralyzing effects of injury and promoting regrowth of functional nerve fibers. Despite the devastating effects of the condition, commercial funding for research investigating a cure after spinal cord injury is limited, partially due to the small size of the population of potential beneficiaries. Despite this limitation, a number of experimental treatments have reached controlled human trials[citation needed].
Advances in identification of an effective therapeutic target after spinal cord injury have been newsworthy, and considerable media attention is often drawn towards new developments in this area. However, aside from methylprednisolone, none of these developments have reached even limited use in the clinical care of human spinal cord injury in the U.S.[citation needed]. Around the world, proprietary centers offering stem cell transplants and treatment with neuroregenerative substances are fueled by glowing testimonial reports of neurological improvement. It is also evident that when stem cells are injected in the area of damage in the spinal cord, they secrete neurotrophic factors, and these neurotrophic factors help neurons and vessels grow, thus helping repair the damage [18] [19] .[20] Independent validation of the results of these treatments is lacking
Sunday, December 12, 2010
Head injury
Classification
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Head injuries include both injuries to the brain and those to other parts of the head, such as the scalp and skull.
Head injuries may be closed or open. A closed (non-missile) head injury is one in which the skull is not broken. A penetrating head injury occurs when an object pierces the skull and breaches the dura mater. Brain injuries may be diffuse, occurring over a wide area, or focal, located in a small, specific area.
A head injury may cause a minor headache skull fracture, which may or may not be associated with injury to the brain. Some patients may have linear or depressed skull fractures.
If intracranial hemorrhage occurs, a hematoma within the skull can put pressure on the brain. Types of intracranial hemorrage include subdural, subarachnoid, extradural, and intraparenchymal hematoma. Craniotomy surgeries are used in these cases to lessen the pressure by draining off blood.
Brain injury can be at the site of impact, but can also be at the opposite side of the skull due to a contrecoup effect (the impact to the head can cause the brain to move within the skull, causing the brain to impact the interior of the skull opposite the head-impact).
If the impact causes the head to move, the injury may be worsened, because the brain may ricochet inside the skull causing additional impacts, or the brain may stay relatively still (due to inertia) but be hit by the moving skull (both are contrecoup injuries).
Specific problems after head injury can include[citation needed]:
* Skull fracture
* Lacerations to the scalp and resulting hemorrhage of the skin
* Traumatic subdural hematoma, a bleeding below the dura mater which may develop slowly
* Traumatic extradural, or epidural hematoma, bleeding between the dura mater and the skull
* Traumatic subarachnoid hemorrhage
* Cerebral contusion, a bruise of the brain
* Concussion, a temporary loss of function due to trauma
* Dementia pugilistica, or "punch-drunk syndrome", caused by repetitive head injuries, for example in boxing or other contact sports
* A severe injury may lead to a coma or death
* Shaken Baby Syndrome - a form of child abuse
[edit] Concussion
Main article: Concussion
Over 4 million concussions are estimated to occur each year [3]
Mild concussions are associated with sequelae. Severity is measured using various concussion grading systems.
A slightly greater injury is associated with both anterograde and retrograde amnesia (inability to remember events before or after the injury). The amount of time that the amnesia is present correlates with the severity of the injury. In all cases the patients develop postconcussion syndrome, which includes memory problems, dizziness, tiredness, sickness and depression.
Cerebral concussion is the most common head injury seen in children.[citation needed]
[edit] Intracranial hemorrhage
Main article: Intracranial hemorrhage
Types of intracranial hemorrhage are roughly grouped into intra-axial and extra-axial. The hemorrhage is considered a focal brain injury; that is, it occurs in a localized spot rather than causing diffuse damage over a wider area.
[edit] Intra-axial hemorrhage
Main article: cerebral hemorrhage
Intra-axial hemorrhage is bleeding within the brain itself, or cerebral hemorrhage. This category includes intraparenchymal hemorrhage, or bleeding within the brain tissue, and intraventricular hemorrhage, bleeding within the brain's ventricles (particularly of premature infants). Intra-axial hemorrhages are more dangerous and harder to treat than extra-axial bleeds.[4]
[edit] Extra-axial hemorrhage
view • talk • edit
Hematoma
type Epidural Subdural
Location Between the
skull and
the dura Between the
dura and
the arachnoid
Involved vessel Middle meningeal
artery Bridging veins
Symptoms Lucid interval
followed by
unconsciousness Gradually increasing
headache and
confusion
Appearance on
CT Lens Crescent-shaped
Extra-axial hemorrhage, bleeding that occurs within the skull but outside of the brain tissue, falls into three subtypes:
* Epidural hemorrhage (extradural hemorrhage) which occur between the dura mater (the outermost meninx) and the skull, is caused by trauma. It may result from laceration of an artery, most commonly the middle meningeal artery. This is a very dangerous type of injury because the bleed is from a high-pressure system and deadly increases in intracranial pressure can result rapidly. However , it is the least common type of meningeal bleeding and is seen in 1% to 3% cases of head injury .
o Patients have a loss of consciousness (LOC), then a lucid interval, then sudden deterioration (vomiting, restlessness, LOC)
o Head CT shows lenticular (convex) deformity.
* Subdural hemorrhage results from tearing of the bridging veins in the subdural space between the dura and arachnoid mater.
o Head CT shows crescent-shaped deformity
* Subarachnoid hemorrhage, which occur between the arachnoid and pia meningeal layers, like intraparenchymal hemorrhage, can result either from trauma or from ruptures of aneurysms or arteriovenous malformations. Blood is seen layering into the brain along sulci and fissures, or filling cisterns (most often the suprasellar cistern because of the presence of the vessels of the circle of Willis and their branchpoints within that space). The classic presentation of subarachnoid hemorrhage is the sudden onset of a severe headache (a thunderclap headache). This can be a very dangerous entity, and requires emergent neurosurgical evaluation, and sometimes urgent intervention.
[edit] Cerebral contusion
Main article: Cerebral contusion
Cerebral contusion is bruising of the brain tissue. The majority of contusions occur in the frontal and temporal lobes. Complications may include cerebral edema and transtentorial herniation. The goal of treatment should be to treat the increased intracranial pressure. The prognosis is guarded.
[edit] Diffuse axonal injury
Main article: Diffuse axonal injury
Diffuse axonal injury, or DAI, usually occurs as the result of an acceleration or deceleration motion, not necessarily an impact. Axons are stretched and damaged when parts of the brain of differing density slide over one another. Prognoses vary widely depending on the extent of damage.
[edit] Symptoms
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Presentation varies according to the injury. Some patients with head trauma stabilize and other patients deteriorate. A patient may present with or without neurologic deficit.
Patients with concussion may have a history of seconds to minutes unconsciousness, then normal arousal. Disturbance of vision and equilibrium may also occur.
Common symptoms of head injury include coma, confusion, drowsiness, personality change, seizures, nausea and vomiting, headache and a lucid interval, during which a patient appears conscious only to deteriorate later.[5]
Symptoms of skull fracture can include:
* leaking cerebrospinal fluid (a clear fluid drainage from nose, mouth or ear) may be and is strongly indicative of basilar skull fracture and the tearing of sheaths surrounding the brain, which can lead to secondary brain infection.
* visible deformity or depression in the head or face; for example a sunken eye can indicate a maxillar fracture
* an eye that cannot move or is deviated to one side can indicate that a broken facial bone is pinching a nerve that innervates eye muscles
* wounds or bruises on the scalp or face.
* Basilar skull fractures, those that occur at the base of the skull, are associated with Battle's sign, a subcutaneous bleed over the mastoid, hemotympanum, and cerebrospinal fluid rhinorrhea and otorrhea.
Because brain injuries can be life threatening, even people with apparently slight injuries, with no noticeable signs or complaints, require close observation. The caretakers of those patients with mild trauma who are released from the hospital are frequently advised to rouse the patient several times during the next 12 to 24 hours to assess for worsening symptoms.
The Glasgow Coma Scale is a tool for measuring degree of unconsciousness and is thus a useful tool for determining severity of injury. The Pediatric Glasgow Coma Scale is used in young children.
[edit] Causes
Common causes of head injury are motor vehicle traffic collisions, home and occupational accidents, falls, and assaults. Bicycle accidents are also a cause of head injury-related death and disability, especially among children. Wilsons disease has also been indicative of head injury. [6]
[edit] Diagnosis
See also: Head injury criterion
The need for imaging in patients who have suffered a minor head injury is debated. A non-contrast CT of the head should be performed immediately in all those who have suffered a moderate or severe head injury.[7]
[edit] Management
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See also: Traumatic_brain_injury#Treatment
Most head injuries are of a benign nature and require no treatment beyond analgesics and close monitoring for potential complications such as intracranial bleeding. If the brain has been severely damaged by trauma, neurosurgical evaluation may be useful. Treatments may involve controlling elevated intracranial pressure. This can include sedation, paralytics, cerebrospinal fluid diversion. Second line alternatives include decompressive craniectomy (Jagannathan et al. found a net 65% favorable outcomes rate in pediatric patients), barbiturate coma, hypertonic saline and hypothermia. Although all of these methods have potential benefits, there has been no randomized study that has shown unequivocal benefit.
[edit] Prognosis
In children with uncomplicated minor head injuries the risk of intra cranial bleeding over the next year is rare at 2 cases per 1 million.[8]
In some cases transient neurological disturbances may occur, lasting minutes to hours. Malignant post traumatic cerebral swelling can develop unexpectedly in stable patients after an injury, as can post traumatic seizures. Recovery in children with neurologic deficits will vary. Children with neurologic deficits who improve daily are more likely to recover, while those who are vegetative for months are less likely to improve. Most patients without deficits have full recovery. However, persons who sustain head trauma resulting in unconsciousness for an hour or more have twice the risk of developing Alzheimer's disease later in life.[9]
Head injury may be associated with a neck injury. Bruises on the back or neck, neck pain, or pain radiating to the arms are signs of cervical spine injury and merit spinal immobilization via application of a cervical collar and possibly a long board.
If the neurological exam is normal this is reassuring. Reassessment is needed if there is a worsening headache, seizure, one sided weakness, or has persistent vomiting.
[edit] See also
* Extra-axial hemorrhage
* Intra-axial hematoma
* Intraparenchymal hemorrhage
* Brain Trauma Foundation
This section does not cite any references or sources.
Please help improve this article by adding citations to reliable sources. Unsourced material may be challenged and removed. (May 2009)
Head injuries include both injuries to the brain and those to other parts of the head, such as the scalp and skull.
Head injuries may be closed or open. A closed (non-missile) head injury is one in which the skull is not broken. A penetrating head injury occurs when an object pierces the skull and breaches the dura mater. Brain injuries may be diffuse, occurring over a wide area, or focal, located in a small, specific area.
A head injury may cause a minor headache skull fracture, which may or may not be associated with injury to the brain. Some patients may have linear or depressed skull fractures.
If intracranial hemorrhage occurs, a hematoma within the skull can put pressure on the brain. Types of intracranial hemorrage include subdural, subarachnoid, extradural, and intraparenchymal hematoma. Craniotomy surgeries are used in these cases to lessen the pressure by draining off blood.
Brain injury can be at the site of impact, but can also be at the opposite side of the skull due to a contrecoup effect (the impact to the head can cause the brain to move within the skull, causing the brain to impact the interior of the skull opposite the head-impact).
If the impact causes the head to move, the injury may be worsened, because the brain may ricochet inside the skull causing additional impacts, or the brain may stay relatively still (due to inertia) but be hit by the moving skull (both are contrecoup injuries).
Specific problems after head injury can include[citation needed]:
* Skull fracture
* Lacerations to the scalp and resulting hemorrhage of the skin
* Traumatic subdural hematoma, a bleeding below the dura mater which may develop slowly
* Traumatic extradural, or epidural hematoma, bleeding between the dura mater and the skull
* Traumatic subarachnoid hemorrhage
* Cerebral contusion, a bruise of the brain
* Concussion, a temporary loss of function due to trauma
* Dementia pugilistica, or "punch-drunk syndrome", caused by repetitive head injuries, for example in boxing or other contact sports
* A severe injury may lead to a coma or death
* Shaken Baby Syndrome - a form of child abuse
[edit] Concussion
Main article: Concussion
Over 4 million concussions are estimated to occur each year [3]
Mild concussions are associated with sequelae. Severity is measured using various concussion grading systems.
A slightly greater injury is associated with both anterograde and retrograde amnesia (inability to remember events before or after the injury). The amount of time that the amnesia is present correlates with the severity of the injury. In all cases the patients develop postconcussion syndrome, which includes memory problems, dizziness, tiredness, sickness and depression.
Cerebral concussion is the most common head injury seen in children.[citation needed]
[edit] Intracranial hemorrhage
Main article: Intracranial hemorrhage
Types of intracranial hemorrhage are roughly grouped into intra-axial and extra-axial. The hemorrhage is considered a focal brain injury; that is, it occurs in a localized spot rather than causing diffuse damage over a wider area.
[edit] Intra-axial hemorrhage
Main article: cerebral hemorrhage
Intra-axial hemorrhage is bleeding within the brain itself, or cerebral hemorrhage. This category includes intraparenchymal hemorrhage, or bleeding within the brain tissue, and intraventricular hemorrhage, bleeding within the brain's ventricles (particularly of premature infants). Intra-axial hemorrhages are more dangerous and harder to treat than extra-axial bleeds.[4]
[edit] Extra-axial hemorrhage
view • talk • edit
Hematoma
type Epidural Subdural
Location Between the
skull and
the dura Between the
dura and
the arachnoid
Involved vessel Middle meningeal
artery Bridging veins
Symptoms Lucid interval
followed by
unconsciousness Gradually increasing
headache and
confusion
Appearance on
CT Lens Crescent-shaped
Extra-axial hemorrhage, bleeding that occurs within the skull but outside of the brain tissue, falls into three subtypes:
* Epidural hemorrhage (extradural hemorrhage) which occur between the dura mater (the outermost meninx) and the skull, is caused by trauma. It may result from laceration of an artery, most commonly the middle meningeal artery. This is a very dangerous type of injury because the bleed is from a high-pressure system and deadly increases in intracranial pressure can result rapidly. However , it is the least common type of meningeal bleeding and is seen in 1% to 3% cases of head injury .
o Patients have a loss of consciousness (LOC), then a lucid interval, then sudden deterioration (vomiting, restlessness, LOC)
o Head CT shows lenticular (convex) deformity.
* Subdural hemorrhage results from tearing of the bridging veins in the subdural space between the dura and arachnoid mater.
o Head CT shows crescent-shaped deformity
* Subarachnoid hemorrhage, which occur between the arachnoid and pia meningeal layers, like intraparenchymal hemorrhage, can result either from trauma or from ruptures of aneurysms or arteriovenous malformations. Blood is seen layering into the brain along sulci and fissures, or filling cisterns (most often the suprasellar cistern because of the presence of the vessels of the circle of Willis and their branchpoints within that space). The classic presentation of subarachnoid hemorrhage is the sudden onset of a severe headache (a thunderclap headache). This can be a very dangerous entity, and requires emergent neurosurgical evaluation, and sometimes urgent intervention.
[edit] Cerebral contusion
Main article: Cerebral contusion
Cerebral contusion is bruising of the brain tissue. The majority of contusions occur in the frontal and temporal lobes. Complications may include cerebral edema and transtentorial herniation. The goal of treatment should be to treat the increased intracranial pressure. The prognosis is guarded.
[edit] Diffuse axonal injury
Main article: Diffuse axonal injury
Diffuse axonal injury, or DAI, usually occurs as the result of an acceleration or deceleration motion, not necessarily an impact. Axons are stretched and damaged when parts of the brain of differing density slide over one another. Prognoses vary widely depending on the extent of damage.
[edit] Symptoms
This section does not cite any references or sources.
Please help improve this article by adding citations to reliable sources. Unsourced material may be challenged and removed. (May 2009)
Presentation varies according to the injury. Some patients with head trauma stabilize and other patients deteriorate. A patient may present with or without neurologic deficit.
Patients with concussion may have a history of seconds to minutes unconsciousness, then normal arousal. Disturbance of vision and equilibrium may also occur.
Common symptoms of head injury include coma, confusion, drowsiness, personality change, seizures, nausea and vomiting, headache and a lucid interval, during which a patient appears conscious only to deteriorate later.[5]
Symptoms of skull fracture can include:
* leaking cerebrospinal fluid (a clear fluid drainage from nose, mouth or ear) may be and is strongly indicative of basilar skull fracture and the tearing of sheaths surrounding the brain, which can lead to secondary brain infection.
* visible deformity or depression in the head or face; for example a sunken eye can indicate a maxillar fracture
* an eye that cannot move or is deviated to one side can indicate that a broken facial bone is pinching a nerve that innervates eye muscles
* wounds or bruises on the scalp or face.
* Basilar skull fractures, those that occur at the base of the skull, are associated with Battle's sign, a subcutaneous bleed over the mastoid, hemotympanum, and cerebrospinal fluid rhinorrhea and otorrhea.
Because brain injuries can be life threatening, even people with apparently slight injuries, with no noticeable signs or complaints, require close observation. The caretakers of those patients with mild trauma who are released from the hospital are frequently advised to rouse the patient several times during the next 12 to 24 hours to assess for worsening symptoms.
The Glasgow Coma Scale is a tool for measuring degree of unconsciousness and is thus a useful tool for determining severity of injury. The Pediatric Glasgow Coma Scale is used in young children.
[edit] Causes
Common causes of head injury are motor vehicle traffic collisions, home and occupational accidents, falls, and assaults. Bicycle accidents are also a cause of head injury-related death and disability, especially among children. Wilsons disease has also been indicative of head injury. [6]
[edit] Diagnosis
See also: Head injury criterion
The need for imaging in patients who have suffered a minor head injury is debated. A non-contrast CT of the head should be performed immediately in all those who have suffered a moderate or severe head injury.[7]
[edit] Management
This section does not cite any references or sources.
Please help improve this article by adding citations to reliable sources. Unsourced material may be challenged and removed. (May 2009)
See also: Traumatic_brain_injury#Treatment
Most head injuries are of a benign nature and require no treatment beyond analgesics and close monitoring for potential complications such as intracranial bleeding. If the brain has been severely damaged by trauma, neurosurgical evaluation may be useful. Treatments may involve controlling elevated intracranial pressure. This can include sedation, paralytics, cerebrospinal fluid diversion. Second line alternatives include decompressive craniectomy (Jagannathan et al. found a net 65% favorable outcomes rate in pediatric patients), barbiturate coma, hypertonic saline and hypothermia. Although all of these methods have potential benefits, there has been no randomized study that has shown unequivocal benefit.
[edit] Prognosis
In children with uncomplicated minor head injuries the risk of intra cranial bleeding over the next year is rare at 2 cases per 1 million.[8]
In some cases transient neurological disturbances may occur, lasting minutes to hours. Malignant post traumatic cerebral swelling can develop unexpectedly in stable patients after an injury, as can post traumatic seizures. Recovery in children with neurologic deficits will vary. Children with neurologic deficits who improve daily are more likely to recover, while those who are vegetative for months are less likely to improve. Most patients without deficits have full recovery. However, persons who sustain head trauma resulting in unconsciousness for an hour or more have twice the risk of developing Alzheimer's disease later in life.[9]
Head injury may be associated with a neck injury. Bruises on the back or neck, neck pain, or pain radiating to the arms are signs of cervical spine injury and merit spinal immobilization via application of a cervical collar and possibly a long board.
If the neurological exam is normal this is reassuring. Reassessment is needed if there is a worsening headache, seizure, one sided weakness, or has persistent vomiting.
[edit] See also
* Extra-axial hemorrhage
* Intra-axial hematoma
* Intraparenchymal hemorrhage
* Brain Trauma Foundation
Dislocated shoulder
Anterior (forward)
Over 95% of shoulder dislocation cases are anterior. Most anterior dislocations are sub-coracoid. Sub-glenoid; subclavicular; and, very rarely, intrathoracic or retroperitoneal dislocations may occur.[2]
It can result in damage to the axillary artery.[3]
[edit] Posterior (backward)
Posterior dislocations are occasionally due to electrocution or seizure and may be caused by strength imbalance of the rotator cuff muscles. Posterior dislocations often go unnoticed, especially in an elderly patient[4] and in the unconscious trauma patient.[5] An average interval of 1 year was discovered between injury and diagnosis of posterior dislocation in a series of 40 patients.[6]
[edit] Inferior (downward)
Inferior dislocation is the least likely form, occurring in less than 1% of all shoulder dislocation cases. This condition is also called luxatio erecta because the arm appears to be permanently held upward or behind the head.[7] It is caused by a hyper abduction of the arm that forces the humeral head against the acromion. Inferior dislocations have a high complication rate as many vascular, neurological, tendon, and ligament injuries are likely to occur from this kind of dislocation.
[edit] Signs
* Significant pain, which can sometimes be felt past the shoulder, along the arm.
* Inability to move the arm from its current position, particularly in positions with the arm reaching away from the body and with the top of the arm twisted toward the back.
* Numbness of the arm.
* Visibly displaced shoulder. Some dislocations result in the shoulder appearing unusually square.
* No bone in the side of the shoulder showing shoulder has become dislocated.
[edit] Treatment
[edit] Initial
Prompt professional medical treatment should be sought for any suspected dislocation injury. Usually, a dislocated shoulder is kept in its current position by use of a splint or sling (however, see below). A pillow between the arm and torso may provide support and increase comfort. Strong analgesics are needed to allay the pain of a dislocation and the anxiety associated with it, and hence, conservative measures of pain relief, should not be attempted.
Emergency department care is focused on returning the shoulder to its normal position via processes known as reduction. Normally, closed reduction, in which several methods are used to manipulate the bone and joint from the outside, is used. A variety of techniques exist, but some are preferred due to fewer complications or easier execution.[8] In cases where closed reduction is not successful, surgical open reduction may be needed.[9] Following reduction, X-Ray imaging is often used to ensure that the reduction was successful and there are no fractures. The arm should be kept in a sling or immobilizer for several days, preferably until orthopedic consultation. Hippocrates' and Kocher's method are rarely used anymore. Hippocrates used to place the heel in the axilla and reduce shoulder dislocations. Kocher's method if performed patiently and slowly can be performed without anesthesia and if done correctly does not cause pain. Traction is applied on the arm and it is abducted. Then, it is externally rotated, and the arm is adducted following which it is internally rotated and maintained in the position with the help of a sling. A chest x-ray should be taken to confirm whether the head of humerus has reduced back into the glenoid cavity.
[edit] Post-reduction: immobilisation in external versus internal rotation
For thousands of years, treatment of anterior shoulder dislocation has included immobilisation of the patient's arm in a sling, with the arm placed in internal rotation (across the body). However, three studies, one in cadavers and two in patients, suggest that the detachment of the structures in the front of the shoulder is made worse when the shoulder is placed in internal rotation to be seen. By contrast, the structures are realigned when the arm is placed in external rotation. New data suggest that if the shoulder is managed non-operatively and immobilised, it should be immobilised in a position of external rotation.[10][11]
Another study found that conventional shoulder immobilisation in a sling offered no benefit[12]
[edit] Surgery
Some cases require non-emergency surgery to repair damage to the tissues surrounding in the shoulder joint and restore shoulder stability. Arthroscopic surgery techniques may be used to repair the glenoidal labrum, capsular ligaments, biceps long head anchor or SLAP lesion and/or to tighten the shoulder capsule.[13]
The time-proven surgical treatment for recurrent anterior instability of the shoulder is a Bankart repair.[14] Surgery to anatomically and securely repair the torn anterior glenoid labrum and capsule without arthroscopy can lessen pain and improve function for active individuals. When the front of the shoulder socket has been broken or worn, a bone graft may be required to restore stability.[15] When the shoulder dislocates posteriorly (out the back), a surgery to reshape the socket may be necessary. Surgery to build up the back of the glenoid socket using an osteotomy and graft can restore shoulder anatomy and lessen pain and improve function. Conversely, there are new procedures that should be investigated as a possible alternative to open surgery
Over 95% of shoulder dislocation cases are anterior. Most anterior dislocations are sub-coracoid. Sub-glenoid; subclavicular; and, very rarely, intrathoracic or retroperitoneal dislocations may occur.[2]
It can result in damage to the axillary artery.[3]
[edit] Posterior (backward)
Posterior dislocations are occasionally due to electrocution or seizure and may be caused by strength imbalance of the rotator cuff muscles. Posterior dislocations often go unnoticed, especially in an elderly patient[4] and in the unconscious trauma patient.[5] An average interval of 1 year was discovered between injury and diagnosis of posterior dislocation in a series of 40 patients.[6]
[edit] Inferior (downward)
Inferior dislocation is the least likely form, occurring in less than 1% of all shoulder dislocation cases. This condition is also called luxatio erecta because the arm appears to be permanently held upward or behind the head.[7] It is caused by a hyper abduction of the arm that forces the humeral head against the acromion. Inferior dislocations have a high complication rate as many vascular, neurological, tendon, and ligament injuries are likely to occur from this kind of dislocation.
[edit] Signs
* Significant pain, which can sometimes be felt past the shoulder, along the arm.
* Inability to move the arm from its current position, particularly in positions with the arm reaching away from the body and with the top of the arm twisted toward the back.
* Numbness of the arm.
* Visibly displaced shoulder. Some dislocations result in the shoulder appearing unusually square.
* No bone in the side of the shoulder showing shoulder has become dislocated.
[edit] Treatment
[edit] Initial
Prompt professional medical treatment should be sought for any suspected dislocation injury. Usually, a dislocated shoulder is kept in its current position by use of a splint or sling (however, see below). A pillow between the arm and torso may provide support and increase comfort. Strong analgesics are needed to allay the pain of a dislocation and the anxiety associated with it, and hence, conservative measures of pain relief, should not be attempted.
Emergency department care is focused on returning the shoulder to its normal position via processes known as reduction. Normally, closed reduction, in which several methods are used to manipulate the bone and joint from the outside, is used. A variety of techniques exist, but some are preferred due to fewer complications or easier execution.[8] In cases where closed reduction is not successful, surgical open reduction may be needed.[9] Following reduction, X-Ray imaging is often used to ensure that the reduction was successful and there are no fractures. The arm should be kept in a sling or immobilizer for several days, preferably until orthopedic consultation. Hippocrates' and Kocher's method are rarely used anymore. Hippocrates used to place the heel in the axilla and reduce shoulder dislocations. Kocher's method if performed patiently and slowly can be performed without anesthesia and if done correctly does not cause pain. Traction is applied on the arm and it is abducted. Then, it is externally rotated, and the arm is adducted following which it is internally rotated and maintained in the position with the help of a sling. A chest x-ray should be taken to confirm whether the head of humerus has reduced back into the glenoid cavity.
[edit] Post-reduction: immobilisation in external versus internal rotation
For thousands of years, treatment of anterior shoulder dislocation has included immobilisation of the patient's arm in a sling, with the arm placed in internal rotation (across the body). However, three studies, one in cadavers and two in patients, suggest that the detachment of the structures in the front of the shoulder is made worse when the shoulder is placed in internal rotation to be seen. By contrast, the structures are realigned when the arm is placed in external rotation. New data suggest that if the shoulder is managed non-operatively and immobilised, it should be immobilised in a position of external rotation.[10][11]
Another study found that conventional shoulder immobilisation in a sling offered no benefit[12]
[edit] Surgery
Some cases require non-emergency surgery to repair damage to the tissues surrounding in the shoulder joint and restore shoulder stability. Arthroscopic surgery techniques may be used to repair the glenoidal labrum, capsular ligaments, biceps long head anchor or SLAP lesion and/or to tighten the shoulder capsule.[13]
The time-proven surgical treatment for recurrent anterior instability of the shoulder is a Bankart repair.[14] Surgery to anatomically and securely repair the torn anterior glenoid labrum and capsule without arthroscopy can lessen pain and improve function for active individuals. When the front of the shoulder socket has been broken or worn, a bone graft may be required to restore stability.[15] When the shoulder dislocates posteriorly (out the back), a surgery to reshape the socket may be necessary. Surgery to build up the back of the glenoid socket using an osteotomy and graft can restore shoulder anatomy and lessen pain and improve function. Conversely, there are new procedures that should be investigated as a possible alternative to open surgery
Tuesday, October 19, 2010
TKR
Knee Replacement
What Is Knee Replacement?
What Is Knee Replacement?
Total knee replacement (TKR), also referred to as total knee arthroplasty (TKA), is a surgical procedure where worn, diseased, or damaged surfaces of a knee joint are removed and replaced with artificial surfaces. Materials used for resurfacing of the joint are not only strong and durable but also optimal for joint function as they produce as little friction as possible.
The "artificial joint or prosthesis" generally has two components, one made of metal which is usually cobalt -chrome or titanium. The other component is a plastic material called polyethylene.
The procedure has been proven to help individuals return back to moderately challenging activities such as golf, bicycling, and swimming. Total knees are not designed for jogging, or sports like tennis and skiing (although there certainly are people with total knee replacements that participate in such sports).
The general goal of total knee replacement is designed to provide painless and unlimited standing, sitting, walking, and other normal activities of daily living
Nice To Know:
With proper care individuals who have had a total knee replacement can expect many years of faithful function. Studies show that patients can expect a greater than 95 percent chance of success for at least 15 years.
If You Are Considering Total Knee Replacement Surgery
If you have been told you have a severely damaged knee joint and would benefit from a total knee replacement, the questions you need to ask yourself are:
1. Have all of the appropriate non-surgical treatments been tried.
2. Is my painful knee significantly restricting my day to day activities and not allowing me to do the things I need to do and the things I enjoy doing?
If the answesr to these questions are yes, you may be a candidate for a new knee.
The Anatomy Of The Knee Joint
The knee joint performs similar to a hinge joint. It consists of three bones:
* Thigh bone (Femur)
* Leg bone (Tibia)
* Knee cap (Patella)
* The junction where the femur and tibia couple together is called the femorotibial joint.
* The region of the knee where the patella and femur form a junction is called the patellofemoral joint.
* These two joints are what allow the bending and straightening of the knee. It is these joints that are replaced in a total knee joint replacement.
For a knee to function normally, the quality of smoothness where each bone moves upon the other becomes important in the function of the knee joint.
The surfaces of all three bones coming into contact with each other are normally covered with a smooth gliding surface known as articular cartilage The smooth lining that covers and protects the bone ends inside a joint.
The condition of this cartilage lining the knee joint is a key aspect of normal knee function and is important to the physician when evaluating a potential need for a knee joint replacement.
In addition to the smooth cartilage lining on the joint surfaces, there are two smooth discs of cartilage that cushion the space between the bone ends. The inner disc is called the medial meniscus A cartilage disk that acts as a cushion or shock absorber between the ends of bones in certain joints. In the knee the disc on the inner side of the knee is called the medial meniscus, and the disc on the outer side is called the lateral meniscus., while the disc on the outer side of the knee joint is called the lateral meniscus. The role of the menisci is to increase the conformity of the joint between the femur and the tibia. The menisci also play an important function as joint shock absorbers by distributing weight-bearing forces, and in reducing friction between the joint segments.
Generally speaking, there are four major ligaments that play an important part in stability of the knee joint. One on each side of the knee (but actually outside the joint) known as collateral ligaments and two more centrally located ligaments within the joint known as anterior and posterior cruciate ligaments.
Facts About Total Knee Replacement
* Total knee replacement surgery helps more than 250,000 Americans get back on their feet each year.
* Over the last twenty-five years, major advancements in artificial knee replacement have greatly improved the outcome of the surgery.
* Technology has led to the development of materials used in the artificial knee joint allowing it to last over fifteen years.
* Artificial joint replacement for arthritis of the knee and hip is one of the most successful surgeries of the last century.
* Individuals are able to begin walking the day following surgery and pain relief is achieved in greater than 95% of people.
Back to Top of Page
Next Page>
Read much more about this topic:
* What Is Knee Replacement?
* What Causes The Knee Joint To Deteriorate?
* Who Is A Candidate For Total Replacement?
* Different Types Of Knee Replacement
* How Is The Artificial Implant Fixed To Bone?
* Possible Risks And Complications
* Preparing For A Knee Replacement
* How Is The Knee Replaced?
* Exercises Following Knee Replacement
* Once You Are Home
* What To Expect After A Knee Replacement
* Getting Back To Your Normal Routine
* When To Contact Your Doctor
* Common Questions
* Putting It All Together
* Glossary
* Sources Of Information
* Home
* All Our Topics
* Contact Us
* Site Map
* Back to Top of Page
Quick Links
Article Navigation
* What Is Knee Replacement?!
* What Causes The Knee Joint To Deteriorate?
* Who Is A Candidate For Knee Replacement?
* Different Types Of Knee Replacement
* How Is The Artificial Implant Fixed To Bone?
* Possible Risks And Complications
* Preparing For A Knee Replacement
* How Is The Knee Replaced?
* Exercises Following Knee Replacement
* Once You Are Home
* What To Expect After A Knee Replacement
* Getting Back To Your Normal Routine
* When To Contact Your Doctor
* Common Questions
* Putting It All Together
* Glossary
* Sources Of Information
What Is Knee Replacement?
What Is Knee Replacement?
Total knee replacement (TKR), also referred to as total knee arthroplasty (TKA), is a surgical procedure where worn, diseased, or damaged surfaces of a knee joint are removed and replaced with artificial surfaces. Materials used for resurfacing of the joint are not only strong and durable but also optimal for joint function as they produce as little friction as possible.
The "artificial joint or prosthesis" generally has two components, one made of metal which is usually cobalt -chrome or titanium. The other component is a plastic material called polyethylene.
The procedure has been proven to help individuals return back to moderately challenging activities such as golf, bicycling, and swimming. Total knees are not designed for jogging, or sports like tennis and skiing (although there certainly are people with total knee replacements that participate in such sports).
The general goal of total knee replacement is designed to provide painless and unlimited standing, sitting, walking, and other normal activities of daily living
Nice To Know:
With proper care individuals who have had a total knee replacement can expect many years of faithful function. Studies show that patients can expect a greater than 95 percent chance of success for at least 15 years.
If You Are Considering Total Knee Replacement Surgery
If you have been told you have a severely damaged knee joint and would benefit from a total knee replacement, the questions you need to ask yourself are:
1. Have all of the appropriate non-surgical treatments been tried.
2. Is my painful knee significantly restricting my day to day activities and not allowing me to do the things I need to do and the things I enjoy doing?
If the answesr to these questions are yes, you may be a candidate for a new knee.
The Anatomy Of The Knee Joint
The knee joint performs similar to a hinge joint. It consists of three bones:
* Thigh bone (Femur)
* Leg bone (Tibia)
* Knee cap (Patella)
* The junction where the femur and tibia couple together is called the femorotibial joint.
* The region of the knee where the patella and femur form a junction is called the patellofemoral joint.
* These two joints are what allow the bending and straightening of the knee. It is these joints that are replaced in a total knee joint replacement.
For a knee to function normally, the quality of smoothness where each bone moves upon the other becomes important in the function of the knee joint.
The surfaces of all three bones coming into contact with each other are normally covered with a smooth gliding surface known as articular cartilage The smooth lining that covers and protects the bone ends inside a joint.
The condition of this cartilage lining the knee joint is a key aspect of normal knee function and is important to the physician when evaluating a potential need for a knee joint replacement.
In addition to the smooth cartilage lining on the joint surfaces, there are two smooth discs of cartilage that cushion the space between the bone ends. The inner disc is called the medial meniscus A cartilage disk that acts as a cushion or shock absorber between the ends of bones in certain joints. In the knee the disc on the inner side of the knee is called the medial meniscus, and the disc on the outer side is called the lateral meniscus., while the disc on the outer side of the knee joint is called the lateral meniscus. The role of the menisci is to increase the conformity of the joint between the femur and the tibia. The menisci also play an important function as joint shock absorbers by distributing weight-bearing forces, and in reducing friction between the joint segments.
Generally speaking, there are four major ligaments that play an important part in stability of the knee joint. One on each side of the knee (but actually outside the joint) known as collateral ligaments and two more centrally located ligaments within the joint known as anterior and posterior cruciate ligaments.
Facts About Total Knee Replacement
* Total knee replacement surgery helps more than 250,000 Americans get back on their feet each year.
* Over the last twenty-five years, major advancements in artificial knee replacement have greatly improved the outcome of the surgery.
* Technology has led to the development of materials used in the artificial knee joint allowing it to last over fifteen years.
* Artificial joint replacement for arthritis of the knee and hip is one of the most successful surgeries of the last century.
* Individuals are able to begin walking the day following surgery and pain relief is achieved in greater than 95% of people.
Back to Top of Page
Next Page>
Read much more about this topic:
* What Is Knee Replacement?
* What Causes The Knee Joint To Deteriorate?
* Who Is A Candidate For Total Replacement?
* Different Types Of Knee Replacement
* How Is The Artificial Implant Fixed To Bone?
* Possible Risks And Complications
* Preparing For A Knee Replacement
* How Is The Knee Replaced?
* Exercises Following Knee Replacement
* Once You Are Home
* What To Expect After A Knee Replacement
* Getting Back To Your Normal Routine
* When To Contact Your Doctor
* Common Questions
* Putting It All Together
* Glossary
* Sources Of Information
* Home
* All Our Topics
* Contact Us
* Site Map
* Back to Top of Page
Quick Links
Article Navigation
* What Is Knee Replacement?!
* What Causes The Knee Joint To Deteriorate?
* Who Is A Candidate For Knee Replacement?
* Different Types Of Knee Replacement
* How Is The Artificial Implant Fixed To Bone?
* Possible Risks And Complications
* Preparing For A Knee Replacement
* How Is The Knee Replaced?
* Exercises Following Knee Replacement
* Once You Are Home
* What To Expect After A Knee Replacement
* Getting Back To Your Normal Routine
* When To Contact Your Doctor
* Common Questions
* Putting It All Together
* Glossary
* Sources Of Information
amputation
What is an amputation?
Why do patients need to undergo amputations?
What sort of amputations can be performed?
How will having an amputation affect me?
What are the risks of amputation surgery?
What are the complications of amputation surgery?
Is it possible to walk after an amputation?
What will happen after my amputation?
What is an amputation?
An amputation usually refers to the removal of the whole or part of an arm/hand or a leg/foot. Amputations can occur after an injury (traumatic amputation) or deliberately at surgery. In vascular surgery amputations are only rarely performed on the arms. Vascular surgeons frequently have to perform amputations of toes or legs. It is one of the oldest surgical procedures with artificial limbs identified from over 2000 years ago.
Why do patients need to undergo amputations?
The vast majority of amputations are performed because the arteries of the legs have become blocked due to hardening of the arteries (atherosclerosis). Blockages in the arteries result in insufficient blood supply to the limb. Because diabetes can cause hardening of the arteries, about 30-40% of amputations are performed in patients with diabetes. Patients with diabetes can develop foot/toe ulceration and about 7% of patients will have an active ulcer or a healed ulcer. Ulcers are recurrent in many patients and approximately 5-15% of diabetic patients with ulcers will ultimately require an amputation. Because hardening of the arteries occurs most commonly in older men who smoke, the majority of amputations for vascular disease occur in this group. Diabetes may be an important factor in nearly 40% of patients undergoing major amputation (Moxey et al 2010).
When hardening of the arteries becomes so severe that gangrene develops or pain becomes constant and severe, amputation may be the only option. If amputation is not performed in these circumstances infection can develop and threaten the life of the patient. Sometimes bypass surgery can be performed to avoid amputation, but not all patients are suitable for bypass surgery. Before amputation, the limb can cause serious problems with infection and pain and may even be a threat to the life of some patients.
Less commonly serious accidents can lead to the loss of a limb, as can the development of a tumour or cancer in a limb. These amputations tend to occur in younger patients.
About 370 new referrals are made to the NZ artificial limb board annually of which about 300 (70%) are due to vascular causes and diabetes. Over the period 2003-2008 in the UK there were approximately 5 major amputations (above or below knee) per 100,000 people (Moxey et al 2010).
Back to the top
What sort of amputations can be performed?
Amputations can be divided into minor and major. Most vascular surgeons will have extensive experience in this type of surgery.
Minor amputations are amputations where only a toe or part of the foot is removed. A ray amputation is a particular form of minor amputation where a toe and part of the corresponding metatarsal bone is removed as shown in the diagram below left. A forefoot amputation can sometimes be helpful in patients with more than one toe involved by gangrene. In this operation all of the toes and the ball of the foot is removed.A second ray amputation
Major amputations are amputations where part of the leg is removed. These are usually below the knee or above the knee.
Occasionally an amputation of just the foot can be performed with a cut through the ankle joint (Symes amputation). This is not suitable for the majority of patients, but can rarely be an option in some patients with diabetes. It is particularly important for this amputation that the posterior tibial artery is patent and has a reasonable blood flow. This artery is found on the inside of the foot just below the ankle. Your surgeon may advise you if this operation may be possible.
Amputations through the knee joint or just above the knee joint (Gritti-Stokes amputation) can also sometimes be performed. They were much more popular amputations in the past but there is little or no advantage for present day patients compared with above knee amputation. If a major amputation is to be performed then a below knee amputation will always give the patient the best chance of remaining mobile and walking post-operatively.
Minor amputations
After minor amputations the wound is not always closed completely with stitches. If infection is present or too much skin has had to be removed then the surgeon may leave the amputation wound open. When a ray amputation is performed the wound is usually left open to heal. This sounds awful and to the untrained eye the resulting wound can appear dreadful. If the wound is open do not be disheartened. If the conditions are right for healing these wounds can heal well over a period of 1-3 months and leave a fully functioning leg and foot. It is possible to walk virtually normally after losing toes. Even after a forefoot amputation where all the toes are removed, walking is usually straightforward.
This sort of operation is performed frequently for foot infections in patients with diabetes.
Major amputations
It is usually possible before the operation (although not always) for the surgeon to decide at what level the amputation will be performed (above knee or below knee). Sometimes gangrene or infection will only involve a toe or part of a foot and a limited or minor amputation can be performed. This is only worthwhile if the surgeon thinks that the wound that is created will heal. In some patients, it is better to try a limited amputation if there is a chance of healing, but to be prepared to proceed to a major amputation if healing doesn't take place.
One of the most important factors in healing is the blood supply to the tissues. If the blood supply is damaged or impaired it may not be possible for the tissues to heal even after a minor amputation. If in the opinion of the surgeon the tissues will clearly not heal because of a poor blood supply it would be reckless to proceed with a minor amputation when really a major amputation is required. Unfortunately, there is no test that can predict in every patient whether healing will take place and it is a matter of surgical judgement and experience whether a wound is likely to heal or not.
In general the more limited the amputation the lower the risks and the better the chances of walking. It is better to have a below knee amputation when compared with an above knee amputation, because the chances of successfully walking after the operation are much better. Unfortunately, not everyone is suitable for this operation and many people need to have an above knee amputation. This may be because the blood supply to the lower leg is too poor and a below knee amputation would not heal properly. If the knee cannot straighten out properly before the surgery (fixed flexion deformity), it will be impossible to walk with an artificial leg after the operation. In these circumstances it may be better to undergo an above knee amputation.
Once an amputation stump is created it is a potentially vulnerable area that will require lifelong care and attention. A major amputation wound is almost always closed with stitches or staples. A major amputation will take approximately 60-90 minutes to perform. Small plastic tubes are often inserted into the stumps before the end of the operation. These are drains which are used to take away any excess fluid that accumulates in the wounds. They are usually removed in the first 48 hours.
Below knee amputation
This operation can be performed using 2 major techniques. The most common technique is the posterior myoplastic flap (Burgess technique) where the skin and muscle from the calf are brought forward to cover the shin bones after they have ben divided (see below left). The other main technique is the skew flap (Kingsley Robinson technique) in which the muscles of the calf are brought forward in the same way as in the posterior technique but the skin flaps are skewed in relation to the muscle. There is no proven advantage for one technique, but sometimes it is easier to perform a skew flap amputation if there has been significant skin damage above the ankle. The bone in the lower leg (tibia) is divided about 12-15 cms below the knee joint. This produces a good size stump to which a prosthesis can be fitted.Below knee amputation
Above knee amputation
In this operation the bone in the thigh (femur) is divided about 12-15 cms above the knee joint and the muscle and skin closed over the end of the bone.
If you wish to see an amputation being performed a short search of the internet will provide many video examples - see here.
Back to the top
How will having an amputation affect me?
Amputation of a limb or limbs will affect people in different ways. It is a very personal loss and in many patients can feel like a bereavement. The emotional loss can be like losing a relative and it will take time to adapt to such a loss. Physically your body will be permanently altered and can affect all areas of your life. How much your amputation affects your life will to some degree depend on the extent of your physical recovery.
There are virtually no activities that a person with an amputation cannot perform with the right help, training and equipment. However, the most important rehabilitation objective for the majority of elderly patients with a lower limb amputation is to walk again. It is important to remember that rehabilitation from an amputation in an elderly person is a much more difficult process than in a young person. Regaining the ability to walk will be a major achievement.
Whether or not a patient will be able to walk following an amputation has been studied by looking at factors present before surgery. Poor pre-operative mobility, age over 70 years, dementia, severe kidney and heart disease are factors which make it unlikely a patient will walk after their amputation (Taylor SM et al, 2005).
What are the risks of amputation surgery?
There are significant risks attached to undergoing an amputation if you are elderly and have hardening of the arteries. In this group of patients the chances of dying in hospital after a major amputation are somewhere between 10% and 20%. In other words between 1 in 10 and 1 in 5 patients, undergoing a major amputation for hardening of the arteries, will die in hospital. This is why amputation is always a last resort and your surgeon will not advise you to undergo this operation unless it is absolutely necessary. Remember these statistics also mean that 4 out of 5 patients undergoing an amputation will do well.
If you are younger and healthy and undergo amputation because of an injury or a tumour, the risks of an amputation are usually much less.
In a UK study examining amputations over the previous 5 years the overall chance of dying from an above knee amputation was 21.4% and was 11.6% for a below knee amputation (Moxey et al 2010). For minor amputations there was a 3.6% risk of dying.
Back to the top
What are the complications of amputation surgery?
The most important complication is the risk of dying. However, there are other complications.
General complications
These mainly consist of problems such as chest infections, angina, heart attacks and strokes. Because your mobility is restricted after an amputation, pressure sores can also develop. The nursing staff particularly will make great efforts to avoid this occurring. Special mattresses and beds are used to reduce pressure on areas at risk of sores. Regular turning to relieve pressure is also important.
Local complications
These mainly consist of wound infections that can develop in the stump. Antibiotics are given to reduce the risk of infection developing at the time of surgery. The stump can sometimes fail to heal or breakdown either as a result of a fall, infection or a poor blood supply. When this happens it can sometimes mean a further operation to revise the amputation or to remove more of the leg.
Sometimes contractures can develop in the knee or hip joint and once present and established can be impossible to correct. The knee or hip will not straighten and then fitting an artificial limb can become impossible. Physiotherapy to keep the joints supple will begin almost immediately after the operation to avoid the risk of contracture.
Deep venous thrombosis can also occur because the veins in the leg will have been tied during the amputation operation and because of the immobility after the surgery. Blood thinners (heparin) will usually be given to reduce the risk of blood clots developing.
Phantom Limb pain
Phantom limb is the sensation of still being able to feel the amputated limb. Most amputees experience this sensation, although the intensity can vary from person to person.
In many patients pain is also experienced in the amputated limb. This is phantom limb pain and can occur in many patients, but is usually fairly mild and self limiting, although it may be a nuisance. In a few patients phantom limb pain can be a serious problem and difficult to treat.
Back to the top
Is it possible to walk after an amputation?
Yes, it is possible to walk after an amputation. How easy it will be to walk depends on a number of factors. For instance it is generally easier to walk with an artificial leg (prosthesis) after a below knee amputation. If you were able to walk normally before your amputation and do not have other illnesses such as angina or breathing difficulties this will also make it more likely you will walk after your amputation.
Some studies have shown that in elderly patients undergoing major amputation (below or above knee) for hardening of the arteries, over half the patients fitted with an artificial leg never used it effectively, especially if rehabilitation was delayed for longer than two months after the amputation. It can take between 6 and 12 months for full rehabilitation potential to be reached.
Most patients undergoing minor amputation will be able to walk virtually normally after surgery.
What will happen after my amputation?
Initially there will be a period of recovery from the operation. Once recovery from the surgery has taken place, physiotherapists and occupational therapists will concentrate on enabling you to manage independently. This will require learning new skills, such as moving from a wheelchair to the bed and back again, using a wheelchair and starting to use an artificial limb. There will be various exercises to strengthen the upper body and maintain flexibility and movement in the amputated leg.
If you are well enough it may be possible to walk on a temporary artificial leg (PAM aid, pneumatic aid to mobilisation) very soon after your operation. This prosthesis has an inflatable section which is placed around the newly formed stump. This can be a very successful method of early rehabilitation, but a permanent made-to-measure artificial leg will be made for you after referral and assessment at the local limb fitting centre. This can only be done when your leg swelling is getting better and may take more than one attempt before the right fit is obtained.
After an amputation the majority of patients need the help of a wheelchair to remain mobile. Sometimes the use of a wheelchair may be the best way of remaining mobile. If you are very elderly or have had other serious illnesses such as heart disease or stroke then it can frequently be better not to be fitted with an artificial leg.
Why do patients need to undergo amputations?
What sort of amputations can be performed?
How will having an amputation affect me?
What are the risks of amputation surgery?
What are the complications of amputation surgery?
Is it possible to walk after an amputation?
What will happen after my amputation?
What is an amputation?
An amputation usually refers to the removal of the whole or part of an arm/hand or a leg/foot. Amputations can occur after an injury (traumatic amputation) or deliberately at surgery. In vascular surgery amputations are only rarely performed on the arms. Vascular surgeons frequently have to perform amputations of toes or legs. It is one of the oldest surgical procedures with artificial limbs identified from over 2000 years ago.
Why do patients need to undergo amputations?
The vast majority of amputations are performed because the arteries of the legs have become blocked due to hardening of the arteries (atherosclerosis). Blockages in the arteries result in insufficient blood supply to the limb. Because diabetes can cause hardening of the arteries, about 30-40% of amputations are performed in patients with diabetes. Patients with diabetes can develop foot/toe ulceration and about 7% of patients will have an active ulcer or a healed ulcer. Ulcers are recurrent in many patients and approximately 5-15% of diabetic patients with ulcers will ultimately require an amputation. Because hardening of the arteries occurs most commonly in older men who smoke, the majority of amputations for vascular disease occur in this group. Diabetes may be an important factor in nearly 40% of patients undergoing major amputation (Moxey et al 2010).
When hardening of the arteries becomes so severe that gangrene develops or pain becomes constant and severe, amputation may be the only option. If amputation is not performed in these circumstances infection can develop and threaten the life of the patient. Sometimes bypass surgery can be performed to avoid amputation, but not all patients are suitable for bypass surgery. Before amputation, the limb can cause serious problems with infection and pain and may even be a threat to the life of some patients.
Less commonly serious accidents can lead to the loss of a limb, as can the development of a tumour or cancer in a limb. These amputations tend to occur in younger patients.
About 370 new referrals are made to the NZ artificial limb board annually of which about 300 (70%) are due to vascular causes and diabetes. Over the period 2003-2008 in the UK there were approximately 5 major amputations (above or below knee) per 100,000 people (Moxey et al 2010).
Back to the top
What sort of amputations can be performed?
Amputations can be divided into minor and major. Most vascular surgeons will have extensive experience in this type of surgery.
Minor amputations are amputations where only a toe or part of the foot is removed. A ray amputation is a particular form of minor amputation where a toe and part of the corresponding metatarsal bone is removed as shown in the diagram below left. A forefoot amputation can sometimes be helpful in patients with more than one toe involved by gangrene. In this operation all of the toes and the ball of the foot is removed.A second ray amputation
Major amputations are amputations where part of the leg is removed. These are usually below the knee or above the knee.
Occasionally an amputation of just the foot can be performed with a cut through the ankle joint (Symes amputation). This is not suitable for the majority of patients, but can rarely be an option in some patients with diabetes. It is particularly important for this amputation that the posterior tibial artery is patent and has a reasonable blood flow. This artery is found on the inside of the foot just below the ankle. Your surgeon may advise you if this operation may be possible.
Amputations through the knee joint or just above the knee joint (Gritti-Stokes amputation) can also sometimes be performed. They were much more popular amputations in the past but there is little or no advantage for present day patients compared with above knee amputation. If a major amputation is to be performed then a below knee amputation will always give the patient the best chance of remaining mobile and walking post-operatively.
Minor amputations
After minor amputations the wound is not always closed completely with stitches. If infection is present or too much skin has had to be removed then the surgeon may leave the amputation wound open. When a ray amputation is performed the wound is usually left open to heal. This sounds awful and to the untrained eye the resulting wound can appear dreadful. If the wound is open do not be disheartened. If the conditions are right for healing these wounds can heal well over a period of 1-3 months and leave a fully functioning leg and foot. It is possible to walk virtually normally after losing toes. Even after a forefoot amputation where all the toes are removed, walking is usually straightforward.
This sort of operation is performed frequently for foot infections in patients with diabetes.
Major amputations
It is usually possible before the operation (although not always) for the surgeon to decide at what level the amputation will be performed (above knee or below knee). Sometimes gangrene or infection will only involve a toe or part of a foot and a limited or minor amputation can be performed. This is only worthwhile if the surgeon thinks that the wound that is created will heal. In some patients, it is better to try a limited amputation if there is a chance of healing, but to be prepared to proceed to a major amputation if healing doesn't take place.
One of the most important factors in healing is the blood supply to the tissues. If the blood supply is damaged or impaired it may not be possible for the tissues to heal even after a minor amputation. If in the opinion of the surgeon the tissues will clearly not heal because of a poor blood supply it would be reckless to proceed with a minor amputation when really a major amputation is required. Unfortunately, there is no test that can predict in every patient whether healing will take place and it is a matter of surgical judgement and experience whether a wound is likely to heal or not.
In general the more limited the amputation the lower the risks and the better the chances of walking. It is better to have a below knee amputation when compared with an above knee amputation, because the chances of successfully walking after the operation are much better. Unfortunately, not everyone is suitable for this operation and many people need to have an above knee amputation. This may be because the blood supply to the lower leg is too poor and a below knee amputation would not heal properly. If the knee cannot straighten out properly before the surgery (fixed flexion deformity), it will be impossible to walk with an artificial leg after the operation. In these circumstances it may be better to undergo an above knee amputation.
Once an amputation stump is created it is a potentially vulnerable area that will require lifelong care and attention. A major amputation wound is almost always closed with stitches or staples. A major amputation will take approximately 60-90 minutes to perform. Small plastic tubes are often inserted into the stumps before the end of the operation. These are drains which are used to take away any excess fluid that accumulates in the wounds. They are usually removed in the first 48 hours.
Below knee amputation
This operation can be performed using 2 major techniques. The most common technique is the posterior myoplastic flap (Burgess technique) where the skin and muscle from the calf are brought forward to cover the shin bones after they have ben divided (see below left). The other main technique is the skew flap (Kingsley Robinson technique) in which the muscles of the calf are brought forward in the same way as in the posterior technique but the skin flaps are skewed in relation to the muscle. There is no proven advantage for one technique, but sometimes it is easier to perform a skew flap amputation if there has been significant skin damage above the ankle. The bone in the lower leg (tibia) is divided about 12-15 cms below the knee joint. This produces a good size stump to which a prosthesis can be fitted.Below knee amputation
Above knee amputation
In this operation the bone in the thigh (femur) is divided about 12-15 cms above the knee joint and the muscle and skin closed over the end of the bone.
If you wish to see an amputation being performed a short search of the internet will provide many video examples - see here.
Back to the top
How will having an amputation affect me?
Amputation of a limb or limbs will affect people in different ways. It is a very personal loss and in many patients can feel like a bereavement. The emotional loss can be like losing a relative and it will take time to adapt to such a loss. Physically your body will be permanently altered and can affect all areas of your life. How much your amputation affects your life will to some degree depend on the extent of your physical recovery.
There are virtually no activities that a person with an amputation cannot perform with the right help, training and equipment. However, the most important rehabilitation objective for the majority of elderly patients with a lower limb amputation is to walk again. It is important to remember that rehabilitation from an amputation in an elderly person is a much more difficult process than in a young person. Regaining the ability to walk will be a major achievement.
Whether or not a patient will be able to walk following an amputation has been studied by looking at factors present before surgery. Poor pre-operative mobility, age over 70 years, dementia, severe kidney and heart disease are factors which make it unlikely a patient will walk after their amputation (Taylor SM et al, 2005).
What are the risks of amputation surgery?
There are significant risks attached to undergoing an amputation if you are elderly and have hardening of the arteries. In this group of patients the chances of dying in hospital after a major amputation are somewhere between 10% and 20%. In other words between 1 in 10 and 1 in 5 patients, undergoing a major amputation for hardening of the arteries, will die in hospital. This is why amputation is always a last resort and your surgeon will not advise you to undergo this operation unless it is absolutely necessary. Remember these statistics also mean that 4 out of 5 patients undergoing an amputation will do well.
If you are younger and healthy and undergo amputation because of an injury or a tumour, the risks of an amputation are usually much less.
In a UK study examining amputations over the previous 5 years the overall chance of dying from an above knee amputation was 21.4% and was 11.6% for a below knee amputation (Moxey et al 2010). For minor amputations there was a 3.6% risk of dying.
Back to the top
What are the complications of amputation surgery?
The most important complication is the risk of dying. However, there are other complications.
General complications
These mainly consist of problems such as chest infections, angina, heart attacks and strokes. Because your mobility is restricted after an amputation, pressure sores can also develop. The nursing staff particularly will make great efforts to avoid this occurring. Special mattresses and beds are used to reduce pressure on areas at risk of sores. Regular turning to relieve pressure is also important.
Local complications
These mainly consist of wound infections that can develop in the stump. Antibiotics are given to reduce the risk of infection developing at the time of surgery. The stump can sometimes fail to heal or breakdown either as a result of a fall, infection or a poor blood supply. When this happens it can sometimes mean a further operation to revise the amputation or to remove more of the leg.
Sometimes contractures can develop in the knee or hip joint and once present and established can be impossible to correct. The knee or hip will not straighten and then fitting an artificial limb can become impossible. Physiotherapy to keep the joints supple will begin almost immediately after the operation to avoid the risk of contracture.
Deep venous thrombosis can also occur because the veins in the leg will have been tied during the amputation operation and because of the immobility after the surgery. Blood thinners (heparin) will usually be given to reduce the risk of blood clots developing.
Phantom Limb pain
Phantom limb is the sensation of still being able to feel the amputated limb. Most amputees experience this sensation, although the intensity can vary from person to person.
In many patients pain is also experienced in the amputated limb. This is phantom limb pain and can occur in many patients, but is usually fairly mild and self limiting, although it may be a nuisance. In a few patients phantom limb pain can be a serious problem and difficult to treat.
Back to the top
Is it possible to walk after an amputation?
Yes, it is possible to walk after an amputation. How easy it will be to walk depends on a number of factors. For instance it is generally easier to walk with an artificial leg (prosthesis) after a below knee amputation. If you were able to walk normally before your amputation and do not have other illnesses such as angina or breathing difficulties this will also make it more likely you will walk after your amputation.
Some studies have shown that in elderly patients undergoing major amputation (below or above knee) for hardening of the arteries, over half the patients fitted with an artificial leg never used it effectively, especially if rehabilitation was delayed for longer than two months after the amputation. It can take between 6 and 12 months for full rehabilitation potential to be reached.
Most patients undergoing minor amputation will be able to walk virtually normally after surgery.
What will happen after my amputation?
Initially there will be a period of recovery from the operation. Once recovery from the surgery has taken place, physiotherapists and occupational therapists will concentrate on enabling you to manage independently. This will require learning new skills, such as moving from a wheelchair to the bed and back again, using a wheelchair and starting to use an artificial limb. There will be various exercises to strengthen the upper body and maintain flexibility and movement in the amputated leg.
If you are well enough it may be possible to walk on a temporary artificial leg (PAM aid, pneumatic aid to mobilisation) very soon after your operation. This prosthesis has an inflatable section which is placed around the newly formed stump. This can be a very successful method of early rehabilitation, but a permanent made-to-measure artificial leg will be made for you after referral and assessment at the local limb fitting centre. This can only be done when your leg swelling is getting better and may take more than one attempt before the right fit is obtained.
After an amputation the majority of patients need the help of a wheelchair to remain mobile. Sometimes the use of a wheelchair may be the best way of remaining mobile. If you are very elderly or have had other serious illnesses such as heart disease or stroke then it can frequently be better not to be fitted with an artificial leg.
Amputation for diabetic foot problems
Amputation for diabetic foot problems
Add save! | | |
Blood vessel and nerve damage associated with diabetes can lead to serious infections that are extremely difficult to treat. Often the first place you have a problem is your feet. When you lose the ability to feel your toes and feet, you are more likely to injure them without knowing it. Even a minor injury, such as a small cut, can develop into an ulcer and a serious infection.
Infections of the feet can spread up into the leg. Sometimes the infection is so severe that the foot and possibly part of the leg must be amputated. In the United States, more than 60% of all lower-leg amputations that are not related to an accident are done because of diabetes.1
Amputations are done when efforts to save the foot or leg are unsuccessful or the infection is causing extensive tissue damage. In all cases, doctors save as much of a person's foot or leg as possible. However, they try to make sure that the remaining part of the limb will heal so that further surgery is not necessary.
A serious infection can be life-threatening. In these cases, an amputation may save your life.
If you are faced with needing an amputation, talk with your doctor about how it can benefit you. Often amputation relieves the severe pain associated with an infection, as well as getting rid of the infection and the need to take strong antibiotics. In addition, modern prosthetic devices are lightweight, making walking as easy as possible after an amputation.
Having a foot or leg amputated is traumatic and means a major body-image change. Allow yourself time to grieve and deal with what losing a part of your body means to you. If you need help, talk with a health professional about emotional counseling. You may also find it helpful to talk with a person who has had an amputatioN.
Add save! | | |
Blood vessel and nerve damage associated with diabetes can lead to serious infections that are extremely difficult to treat. Often the first place you have a problem is your feet. When you lose the ability to feel your toes and feet, you are more likely to injure them without knowing it. Even a minor injury, such as a small cut, can develop into an ulcer and a serious infection.
Infections of the feet can spread up into the leg. Sometimes the infection is so severe that the foot and possibly part of the leg must be amputated. In the United States, more than 60% of all lower-leg amputations that are not related to an accident are done because of diabetes.1
Amputations are done when efforts to save the foot or leg are unsuccessful or the infection is causing extensive tissue damage. In all cases, doctors save as much of a person's foot or leg as possible. However, they try to make sure that the remaining part of the limb will heal so that further surgery is not necessary.
A serious infection can be life-threatening. In these cases, an amputation may save your life.
If you are faced with needing an amputation, talk with your doctor about how it can benefit you. Often amputation relieves the severe pain associated with an infection, as well as getting rid of the infection and the need to take strong antibiotics. In addition, modern prosthetic devices are lightweight, making walking as easy as possible after an amputation.
Having a foot or leg amputated is traumatic and means a major body-image change. Allow yourself time to grieve and deal with what losing a part of your body means to you. If you need help, talk with a health professional about emotional counseling. You may also find it helpful to talk with a person who has had an amputatioN.
Tuesday, August 3, 2010
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